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87-197
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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87-197
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Last modified
11/6/2019 10:08:46 PM
Creation date
12/5/2017 7:40:14 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
87-197
PE
4210
STREET_NUMBER
16886
STREET_NAME
AUSTIN
STREET_TYPE
RD
City
MANTECA
SITE_LOCATION
16886 AUSTIN RD MANTECA
RECEIVED_DATE
02/03/1987
P_LOCATION
T OSBORNE
Supplemental fields
FilePath
\MIGRATIONS\A\AUSTIN\16886\87-197.PDF
QuestysFileName
87-197
QuestysRecordID
1650078
QuestysRecordType
12
Tags
EHD - Public
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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. /� J� I <br /> Job Address `Q D6 S 1�� kooo City r.r1�A' Lot Size i �� " PM <br /> Owner's Name ��1 S Q f 'P, Address C-1 6 41 E, Phone <br /> /� y�� 7 <br /> Contractor Address 1 Q /S'U�c' , License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑;Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by y <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTAL)ATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Ito/ available within 200 feet.) <br /> Installation will serve: Res' ence_ Commercial_ Other <br /> Number of living units:T Number of bedrooms <br /> Character of soil to a depth of 3 feet: 4S�4.q C/ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ✓✓✓ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line C <br /> LEACHING LINE Ff" No. & Length of lines Q Total length/size F <br /> A , <br /> FILTER BED ❑ Rstance.to nearest: Well Foundation," 3'0 Property Line <br /> SEEPAGE PITS ❑ Depth Size Number 4.• <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> MAL b �G� Title: kc�. I'l Date: � �Q D7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � 6t`4__ r1 Date ' Area f/' <br /> Pit or Grout Inspection by Date Final Inspection by' wje4 Date 1", 7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental fiealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stir., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. <br /> + EH 13-24(REV.1/05) , QQ <br /> EH 1426 Zf3�F-7 S7 <br /> 4q <br />
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